Abstract
The victims of medical error reach far beyond the patient. The aftermath forever changes the lives of the patient’s family and physician alike. We explore the life and death of nineteen-year-old Matt, a stellar athlete and better son, and the cognitive bias that led to an unfortunate and consequential medical misdiagnosis. This story is one of family heartbreak, the harsh reality of second victim phenomenon, and ultimately lessons learned in compassion, vigilance, and candidness for the health care industry. We share this tragedy with the medical community in hopes that we improve the use of post-mortems, transparency and disclosure to heal the wounds of our patients’ families.